Pre-hospital Rapid Sequence Intubation

Dr Peter Sherren

Senior registrar Anaesthesia, Intensive Care and Pre-hospital care The Royal London Hospital and Greater Sydney Area HEMS

Objectives•Why?•Who?• How?• Evidence

Introduction• Controversial/Territorial/Evocative topic!• Early appropriate airway control central to

good trauma care• Why not bring a hospital level of care to the

roadside?

Why?• Like haemorrhage, airway compromise is a

significant cause of preventable deaths• Hypoxia common on scene in trauma. Stochetti et al. J

Trauma 1997

• Hypoxia and hypercarbia associated with increased morbidity and mortality in TBI. Sherren PB et al. Curr Opin Anesthesiol 2012

• ETI is gold standard in hospital• Patient and pathology have no respect for

geography

How? - Intubation without drugs or sedation only

• Successful ETI of trauma pts without drugs ~ mortality 99.8%. Lockey D et al. BMJ 2001.

• Low success rates in patients with reflexes intact (5-30%)

• ETI with sedation• Still a low success rate• ↑Secondary brain injury• ↑Mortality

SOLUTION = RAPID SEQUENCE INTUBATION

(RSI)?

Components of RSI

• Preoxygenation• Premedication• Rapid induction of Anaesthesia• MILS ± Cricoid• Rapid onset neuromuscular relaxation• Ideally no BVM ventilation• ETI and confirmation• Maintenance of Anaesthesia and paralysis

Components of RSI

• Preoxygenation• Premedication• Rapid induction of Anaesthesia• MILS ± Cricoid• Rapid onset neuromuscular relaxation• Ideally no BVM ventilation• ETI and confirmation• Maintenance of Anaesthesia and paralysis

Drug assisted definitive airway control

Minimising time from induction to ETI

Decreased gastric insufflation

Decreased risk of hypoxia and aspiration

Controversies • Optional Premedictions

• Sedate to preoxygenate (midazolam vs ketamine)• Opioid (Fentanyl 1-3mcg/kg) to obtund hypertensive

response to laryngoscopy and ICP spikes• Fluid/blood bolus in hypovolaemic• Atropine in paeds

• Induction agent? (much lower doses in hypovolaemic)• Midazolam (0.3mg/kg)• Propofol (1.5-2.5mg/kg)• Thiopentone (3-5mg/kg) Reconstitution, SVR issues• Etomidate (0.3mg/kg) 11β/17α hydroxylase inhibition• Ketamine (1-2mg/kg) CLOSE TO IDEAL AGENT

Controversies • Optional Premedictions

• Sedate to preoxygenate (midazolam vs ketamine)• Opioid (Fentanyl 1-3mcg/kg) to obtund hypertensive

response to laryngoscopy and ICP spikes• Fluid/blood bolus in hypovolaemic• Atropine in paeds

• Induction agent? (much lower doses in hypovolaemic)• Midazolam (0.3mg/kg)• Propofol (1.5-2.5mg/kg)• Thiopentone (3-5mg/kg) Reconstitution, SVR issues• Etomidate (0.3mg/kg) 11β/17α hydroxylase inhibition• Ketamine (1-2mg/kg) CLOSE TO IDEAL AGENT

Controversies• Neuromuscular blockade

• Suxamethonium (1.5-2mg/kg) – Rapid, familiarity and obvious fasciculation end point but dirty drug• Rocuronium (1.2mg/kg) – Rapid, improved side effect

profile and prolonged safe apnoea time

• Cricoid pressure - poor evidence & ↑ Difficult intubation. Harris T et al. Resuscitation 2010

Bottom line• Generally right drug, at the right time, at the

right dose………

• Pre-hospital=high risk → Simplified evidence based Standard Operating Procedures (SOP)

• Remove individual practice in high risk environment, improve CRM and reduce human error

Not controversial• Pre-hospital environment is no excuse for low

standards of care• Rigorous training, simulation, assessment and currencies• Trained operator and assistant• AAGBI standard of monitoring (ECG, NiBP, SpO2, waveform

ETCO2)• Quality control/assurance as part of good clinical governance

• Preoxygenation• Non-rebreath mask or BVM ± PEEP valve• Nasal cannula oxygen 15L/min. PreO2 + DAO• Consider OPA/NPAx2/SGA

Still not controversial• MILS - remove C-collar• Maximise 1st pass

intubation success• Control your environment • 360 degree access• Optimise position • Use bougie for all cases• Standardised equipment and

techniques• Formalised failed intubation

and oxygenation drills

Who?

• Impending or actual failure of airway patency• Failure of airway protection• Oxygenation or ventilation failure• Injured patients who are unmanageable or

severely agitated after head injury• Humanitarian indications• Anticipated clinical course

So we think pre-hospital RSI has a place, but who should be doing it?

↓

A TRAINED AND COMPETENT TEAM

Physician-paramedic team• Good medical

experience• Anaesthetic

experience• Doctor ≠ pre-hospital

RSI competent!• Additional pre-hospital

training • Cost• Availability

Double Paramedic or paramedic/air crewman

• At home in the pre-hospital environment

• Experienced++• Infrastructure and

governance needed• Infrequent occurrence

for those purely working out of hospital; skill maintenance issue

Do paramedics want to do it?

• 99 London HEMS paramedics were asked if they felt RSI should be part of experienced UK paramedic’s practice (courtesy of Prof D Lockey)

• 65% said yes pre-term at London HEMS• Only 32% said yes on completion of their term working

for HEMS

• Isolated to London HEMS?

Success rates of pre-hospital RSI• Physician/paramedic team• 99.4% London HEMS (348/350) Mackay CA et al. Emerg Med J 2001

• 98.8% London HEMS (397/402) Harris T et al. Resuscitation 2010

• 99.5% GSA-HEMS (185/186) Bloomer R et al. Emerg Med J 2012

• 99.1% SAMU France (685/691) Adnet F et al. Ann Emerg Med 1998

• 100% Germany (342/342) Helm M et al. Br J Anaesth 2006

• Paramedic• 97% MICA Victoria (152/157) Bernard SA et al. Ann Surg 2010

• 96% Auckland rescue helicopter (~280) Tony Smith

• 86.7% San Diego (281/209) Davis DP et al. J Trauma 2003

Are failed intubations an issue?• Yes, but.... • Can’t Intubate Can’t Oxygenate much worse• Failure to detect an oesophageal intubation or misplaced

ETT is much worse• Undetected oesophageal intubations during RSI should

really be a ‘NEVER’ event• Continuous ETCO2 monitoring reduces UNDETECTED

misplaced intubations from 23.3% to 0%. Silvestri S et al. Ann Emerg Med 2005

Waveform capnography/ETCO2

• 209 RSI, 627 historical controls• Mortality - RSI vs control, 33% vs 24% (p <0.05)• Good outcome – RSI vs control, 57% vs 45% (p <0.01)• High rates of hypotension, hypoxaemia, hypercarbia• Low intubation success• Longer scene times• Training issue?• Use of ETCO2 not universal

• 312 pts RCT• MICA paramedics with ETCO2• Midazolam/Sux• 97% success rate, 5 oesophageal intubations recognised• Favourable outcome - 51% pre-hospital RSI compared 39%

controls (p <0.05)• 13 lost to follow up, 1 more +ve outcome in control group

would result in NS result

• Prospective RCT by Careflight, awaiting publication• Physician/paramedic vs standard care• 338 recruited over 6yrs, needed 510 pts• -ve primary outcome (GOSE 6 months)• High cross over between groups• When ASNSW physician/paramedic team added to

careflight team data -> improved odds of survival at discharge (p-0.02)

Pre-hospital RSI is here to stay, so how do we make it safer?

PRE-HOSPITAL RSI↓

KEEP IT SIMPLE↓

STANDARDISE PRACTICE (equipment, techniques and drugs)

↓AVOID HUMAN ERROR

↓IMPROVE CRM

Standard Operating procedures

Standardised pre-hospital drugs

• Pre-drawn drugs• Ketamine 200mg/20ml• Suxamethonium 100mg/2ml (x2)• Midazolam 10mg/10ml• Morphine 10mg/10ml

• Spare Ampoules• Rocuronium 50mg/5ml (x2)• Fentanyl 500mcg/10ml (x2)• Midazolam 15mg/3ml • Ketamine 200mg/2ml (x5)

In hospital level of monitoring and Kit dump

Challenge response checklist

Quality assurance and clinical governance

Training and simulation

Summary• Pre-hospital RSI is indicated in certain patients• High risk intervention that needs to be

delivered in a quality assured manner• Pre-hospital RSI done badly is worse than

standard management• Some evidence for a morbidity and mortality

benefit

Questions?